Motivational Interviewing

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Motivational Interviewing

• An Introduction to Spirit and Style

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A taste of Motivational Interviewing
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What is Motivational Interviewing?

• It is a communication style that is
• Evocative
• Collaborative
• Supportive of autonomy
• Exploratory
• Empathetic
• Directive

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What else?

• Motivational Interviewing is evidenced based
• 3 decades of research
• More than 200 published clinical trials
• Effective for an array of targeted problems
• Cardiovascular rehabilitation
• Diabetes management
• Dietary change
• Smoking
• Gambling
• Drug use / problem drinking
• Management of chronic mental disorders
• And others

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What else?

• MI is a Method that is
• Teachable
• Observable
• Measurable
• Learnable by a broad range of helping
  professionals
• Complementary to other treatment methods

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Goals of Motivational Interviewing

• Lack of motivation is often ambivalence
• The person feels 2 ways about the proposed change
• Resistance is often the argument why not to
  change
• MI attempts to help the individual resolve the
  ambivalence, so that it no longer hinders the
  process of change.

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How?Combining Spirit and Technique

• MI Spirit is ACE
• Autonomy rather than authority
• Affirms the persons right and capacity for
  self-direction
• Collaborative rather than confrontational
• Counseling is a partnership that honors the
  persons experiences and ideas
• Evocative rather than educating
• The resources and motivation to change are
  presumed to reside within the person

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MI Spirit
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Four Principles that are part of Spirit

• Express Empathy
• Acceptance facilitates change
• Skillful reflective listening is fundamental
• Ambivalence is normal
• Develop Discrepancy
• The client rather than the counselor should
  present the arguments for change
• Change is motivated by a perceived discrepancy
  between present behavior and important goals or
  values

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Four Principles that are part of Spirit

• Roll with Resistance
• Avoid arguing for change
• Resistance is not directly opposed
• New perspectives are invited but not imposed
• Resistance is a signal to respond differently
• Support Self-Efficacy
• A persons belief in their ability to change
  matters
• The client is responsible for choosing change
• The counselors belief in the persons ability to
  change is a self-fulfilling prophecy

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Technique OARS

• Open questions
• Not short-answer, yes/no, or rhetorical
• Affirm
• Comment positively on strengths, effort,
  intention
• Reflective Listening
• Summarizes meaning
• A statement, not a question
• Summarize
• Draw together the persons own perspectives on
  change

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Reflections

• Levels of reflection
• Repeat direct restatement of what the person
  said
• Rephrase saying the same thing in slightly
  different words
• Paraphrase Making a guess about meaning
  continuing the paragraph usually adds something
  that was not said directly. Takes it to the
  next level
• Other types of reflection
• Double-sided reflection states both sides
• Amplified reflection overstates what was said

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What if you could predict the potential that the
person will change?

• Change Talk (DARN)
• Desire want, prefer, wish
• Ability able, can, could, possible
• Reason specific arguments for change
• Need important, have to, need to
• Commitment Language
• This predicts actual change

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Eliciting Change Talk

• Ask for it use open questions to elicit desire,
  ability, reason and need
• In what ways would it be good for you to ____?
• If you decide to ____, how would you do it?
• What would be good about ____?
• Why would you want to ____?
• Dont forget about ambivalence
• What would be good / what would be not-so-good?

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Eliciting Change Talk

• Use of Importance and Confidence rulers
• On a scale of 0-10, how important is it for you
  to ___?
• Why are you at a ____ and not zero? (Change
  talk)
• On a scale of 0-10, how confident are you that
  you could ____?
• Why are you at ____ and not zero? (Ability talk)
• Looking Forward
• If you dont make change, what do you think will
  happen?
• Where would you like to be in ____ years?
• What do you hope would be different?
• How does ____ fit into that?

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Responding to Change Talk

• When you hear it
• Reflect what was said
• Ask for elaboration
• Attempt to elicit more
• Affirm the change talk
• Use Summaries to gather together the pieces of
  change talk
• Strengthen Commitment Language

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Strength of Commitment Language

• HIGH
• I will / promise / swear / guarantee
• I intend to / agree to / am ready to
• I plan / expect / resolve / aim to
• I hope to / will try to / will see about
• I guess / think / suppose I will
• LOW

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Giving Advice

• The person is more likely to hear and accept
  advice if you have permission to give it
• Three forms of permission
• The person asks for it, your opinion
• You ask permission to give it
• Preface your advice with permission to
  disagree/disregard it

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Responding to Resistance

• Remember that Resistance is just a side of
  ambivalence
• Dont argue against it if you push they will
  push back
• Rolling with resistance helps decrease it

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Rolling with Resistance

• Use of reflection as a response
• Simple reflection
• Amplified
• Overstating the reflection
• Double-Sided
• Naming both sides of the ambivalence
• Shifting the focus
• Acknowledge the concerns and move the discussion
  in a less stressful direction
• Reframing
• Validate from a slightly different angle

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Rolling with Resistance

• Emphasize the persons
• Ability to choose
• Control of the situation
• Autonomy
• Come along side
• Defend the status-quo side of your clients
  ambivalence to minimize defensiveness and
  encourage him to make the case for change.

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Counselor responses that may elicit resistance

• Arguing for change
• Carry the banner for change, and seek to persuade
• Assuming the expert role
• The counselor has the answers
• Criticizing, shaming, blaming
• Attempting to instill negative emotions about the
  status quo

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Counselor responses that may elicit resistance

• Labeling
• Pushing acceptance of a specific label or
  diagnosis to characterize the persons behavior
• Being in a hurry
• If you act like you only have a few minutes, it
  can take all day. Monty Roberts
• Claiming preeminence
• I know what is best

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Traps to Avoid

• Question Answer Trap
• Pattern of questions followed by short answers
• Taking Sides
• Identifying the problem and the need to change it
• Expert Trap
• Responsibility falls on the counselor to have all
  the answers

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Traps to Avoid

• Labeling Trap
• Counselor naming vs. individuals naming
• Premature-Focus Trap
• Attempting to draw the person to the problem area
  as defined by the counselor
• Blaming Trap
• Whose fault is the problem? Whos to blame?

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The Transtheoretical ModelStages of Intentional
Change

• By, DiClemente and Proskaska, 1985
• Not Motivational Interviewing
• Developed independently
• Developed around the same time
• Fits well with Motivational Interviewing
• Stages of changes is a way of looking at where a
  person is at
• Motivational Interviewing addresses what to do
  about it

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Stages of Change

• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance

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Pre-contemplation

• HAS no awareness of the connection between a
  particular self-defeating behavior and the
  negative consequences it is causing them.
• NEEDS help focusing on personal values and life
  goals - things he wants and doesnt want in his
  life - an accepting person to hear him without
  judging, advising, or directing.
• TO . Raise his awareness and create a safe
  interpersonal space

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Intervention

• Establish rapport, build trust (OARS)
• Offer factual information without judgment
• Express concern
• Dont push into action
• Dont give up

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Contemplation

• HAS a growing awareness of the connection
  between the problem behavior and its negative
  consequences - cognitive dissonance and
  emotional turmoil.
• NEEDS to more clearly see the discrepancy
  between her personal values and goals and the
  consequences of her current behavior -
  non-judgmental support.
• TO facilitate movement toward change.

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Intervention

• Normalize ambivalence
• Discuss the pros and cons of change
• Emphasize freedom of choice
• Support self-confidence

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Preparation for Action

• HAS a growing readiness and willingness to
  eliminate the problem behavior along with some
  experimentation with replacement behaviors.
• NEEDS help planning, refining, and monitoring
  small, meaningful, measurable goals - respectful
  advise, a menu of options, and support.
• TO foster success and boost confidence.

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Intervention

• Clarify the persons goals
• Collaboratively develop a menu of options
• Consider and lower barriers (e.g. child care,
  transportation, etc)
• With permission, offer advice

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Action

• HAS developed and practiced alternatives to the
  problem behavior.
• NEEDS the benefits of adopting the new
  behavior to remain more powerful and meaningful
  than the costs of letting go of the old
  behavior.
• TO sustain momentum while keeping the memory
  green

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Intervention

• Acknowledge difficulties in putting the plan into
  action
• Identify high risk situations and develop coping
  skills
• With the person assess social and material
  supports

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Maintenance

• HAS succeeded in establishing replacement
  behaviors - an ongoing need for modifications in
  the action plan.
• NEEDS positive reinforcement - relapse
  prevention strategies.
• TO protect against loss of focus, courage, and
  hope - increase self-confidence.

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Intervention

• Affirm their resolve and self-efficacy
• Help the person practice and use new coping
  strategies
• Maintain supportive contact
• Re-view them long-term goal/s

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To Learn More

• Read the book
• Miller, WR. Rollnick, S. Motivational
  Interviewing Preparing people for change. Vol.
  2nd ed.. New York Guilford Press 2002.
• Check out the Website
• www.motivationalinterview.org
• Get the Training Tapes
• Miller, WR. Rollnick, S. Moyers, TB.
  Motivational Interviewing (7 videotape series).
  Albuquerque University of New Mexico 1998.
• Get more training
• MINT Members
• Consult with others
• Chad Hale, LMSW, CAAC
• Pathways, CMH. [phone]